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Nonperforating Cyclodiathermy for the Treatment of Glaucoma*
NONPERFORATING CYCLODIATHERMY FOR T H E T R E A T M E N T O F GLAUCOMA* FRANK C. LUTMAN, M.D.* Rochester, New York
Vogt and his associates 1 ' 2 - 3 - have recently introduced the cyclodiathermy operation for the treatment of glaucoma. The operation employs a diathermy needle similar to that used for retinal separation to destroy a portion of the ciliary body by multiple punctures through the overlying sclera. An atrophy of the ciliary body has been confirmed histologically ;*■ * therefore a reduction in the formation of aqueous would be expected to follow. Vogt's procedure has been designated as "perforating cyclodiathermy" to distinguish it from the "nonperforating" method employed by Albaugh and Dunphy,4 who used contact with a broad electrode to the sclera over the ciliary region. The following report is based upon the observations made on 28 eyes afflicted with various types of glaucoma which were treated by nonperforating cyclodiathermy. The operative procedure followed closely the originally described method.4 Subsequent to instillation of an anesthetic and a retrobulbar injection of procaine and adrenalin, a conjunctival flap was reflected toward the limbus over half the eyeball. The tip of a 2-mm. rounded electrode was used in the earlier operations, and later the flat end of a round stainless-steel pin 2 mm. in diameter. A small Bovie high frequency electro-surgical unit set at 35-40 furnished the coagulation current. The electrode was held in contact with the sclera from 4 to 5 seconds to form a single row of points over the * From the Department of Surgery, The University of Rochester School of Medicine and Dentistry, and The Strong Memorial Hospital. t Now Lt. ( M C ) , A.U.S. 180
ciliary region. The amount of current, the time, and the degree of pressure upon the sclera are all variable and arbitrary. The optimum area of coagulation was for the 2 mm. covered by the tip of the electrode and extending for not more than 0.5 mm. beyond its edge. Coagulation exceeding this amount led to an excessive postoperative reaction. A closure with a tight running silk suture was found the most effective means of avoiding a postoperative retraction of the conjunctiva with an exposure of the treated portion of the sclera. In the few instances where retraction occurred, the sclera was slow in healing. Because of the possible danger of too extensive destruction to the anterior circulation of the eye, no more than twothirds of the ciliary body was treated in any one eye. At first, because intraocular pressure was not immediately relieved by the operation, there was hesitation in employing atropine postoperatively. Later atropine was used routinely and in most instances was continued until the uveitis subsided. At the first dressing of the atropinized eyes, the pupils were dilated only in the segment not operated upon. These pupils remained permanently oval, and the iris failed to respond to light over the segment that had undergone operation. Usually there was ocular pain for about 24 hours postoperatively, at which time the eyes were comfortable regardless of any abnormally high intraocular pressure. Albaugh and Dunphy4 attribute a postoperative rise in tension to a mechanical shrinking of the sclera with reduction of the total contents of the eyeball. Apart from this action there is the effect of the adrenalin used, for adrenalin temporarily
DIATHERMY FOR THE TREATMENT OF GLAUCOMA reduces intraocular pressure in a glaucomatous eye although it may later induce a stasis and edema.5 The elevated tension is probably due principally to the injurious effect of the diathermy upon the endothelium of those vessels of the ciliary body that are not actually destroyed. The injury is comparable to a burn upon the body surface where the transudate accumulates in cutaneous blebs. Occurring within the unyielding confines of the eyeball, this process is followed by extreme elevation of intraocular pressure. Occasionally, to counteract this, the operation was followed by a paracentesis sufficiently large to remain open for at least 24 hours. In most instances intraocular pressure dropped slowly and steadily for several days before it returned to normal. There was a further reduction to a point of extreme hypotony, lasting for weeks or until the uveitis subsided, when the tension returned to normal or again became elevated. During the stage of hypotony the anterior chamber was reduced as much as a third of normal depth. Several eyes were tender during this period. The preoperative incompensation and high tension were never reached by such eyes as returned to a glaucomatous state postoperatively. A most striking sequel of the operation was the relief from ocular pain. A constant occurrence was a faint opacification with anesthesia of one half to two thirds of the corneal surface corresponding to the treated segment of the bulbs. When three fifths of the ciliary region was treated, as much as four fifths of the cornea became anesthetic. For several subsequent weeks this hazy and anesthetic portion of the cornea dried quickly upon exposure. Later the corneal smoothness was completely restored, although in a few cases there were permanent deep nebulous opacities. These, however, may have arisen from the glaucoma. Corneal anesthesia over the segment
181
where it was first observed remained complete and unchanged in all these cases except one, where slight sensitivity returned. Some cases were under observation for more than two years. A number of cyclodiathermies were done upon the upper part of the bulb so that the anesthetic portion of the cornea was protected by the upper lid. This position of the cyclodiathermy did not interfere with a subsequent cataract extraction through an enlarged superiorly located keratome incision under a conjunctival flap in case 19. In case 13, the cyclodiathermy was below, the cataract incision located above. A uveitis with a cyclitis of variable severity and duration follows the necrosis of the ciliary body and overlying sclera. In this series there was a greatly increased aqueous ray which sometimes lasted for months. However, cells were infrequent in the anterior chamber. Some degree of posterior synechia usually occurred, and a mild iris atrophy was a frequent late finding. A thin membrane formed across the pupillary area of the aphakic eyes. Unless emptied by paracentesis, the anterior chamber usually remained at least partly formed, which is favorable in avoiding peripheral synechia. Danger of a direct thermal injury to the lens at operation seems improbable. Following any of the usual operations for glaucoma, even when no apparent injury occurs to the lens, cataractous changes are prone to form. With the use of cyclodiathermy a sudden acute fall of intraocular pressure is avoided. A possible danger to the lens exists in its exposure to an extreme hypotony, an iridocyclitis, and to the degenerative products from the tissues destroyed by the diathermy current. In spite of the destruction of a substantial part of the aqueous-forming structures, some eyes returned to an abnormally high tension when recovery from the operation had occurred and when the
182
FRANK C. LUTMAN TABLE 1 DATA ON 28 CASES OF GLAUCOMA TREATED WITH CYCLODLVTHERMY gex
Diagnosis and Previous Treatment
Vision and Tension before Cyclodiathermy
80
d"
Eye blind for 7 yrs. Iris atrophic, vascularized.
No light perception; tension 55 mm. Hg
2.
59
3.
Case A
Cyclodiathermy
Results
Lower 1/3
4 dys. postoperatively, tension 30 mm.; 3 wks., 21; 2 mos., 16.
d"1 Bilateral old retinal separations. Left eye painful, irritated. Mild diabetes.
Nolight percepUpper 2/5 tion; tension 90 mm. Hg
76
9
Acute congestive glaucoma 10 wks. following extracapsular combined lens extraction. Miotics failed.
6/200 (previous to cataract removal) ; tension 90 + mm. Hg
Upper 3/5
1 month postoperatively, tension 35 mm. No pain. Patient died soon after this from uremia. Tension followed for 16 mos. never above 21 mm. Corrected vision 6/7.5—2; Field, white 3/1000 3 5 8 27
4.
67
9
Irritation and pain 10 wks. after right central venous thrombosis. Miotics failed.
Light perception; tension 90 mm. Hg
Upper 3/5
1 wk. postoperatively, tension 42 mm.; 2 wks., 30; 5 wks., 25; 6 wks., 35.
5.
80
9
Right eye painful and congested for 10 dys. following central venous thrombosis of unknown duration.
Light perception; tension 90 mm. Hg
Upper 1/2
2 dys. postoperatively, tension 47 mm.; 4 dys., 55; 4 wks., 65; 5 wks., 80. No pain. Light perception.
6.
60
c? Left extracapsular lens extraction,* iridencleisis* 4 yrs. previously. Eye painful, congested.
No light perception; tension 9 0 + mm. Hg
Lower 1/2 (lightly)
2 dys. postoperatively, tension 35 mm.; 3 dys., 23; 3 mos., 55. No pain.
7.
66
9
Intracapsular combined cataract extraction* 1 yr. previously. Compensated glaucoma. Miotics failed.
6/10; tension 56 mm. Hg
Upper 2/3
1 dy. postoperatively, tension 21 mm.; 21 mos., 21. Corrected vision 6 / 1 0 - 2 ; Field 15 40 15 38
8,9.
52
In May, 1942, left acute congestive glaucoma for 33 dys.; right for 4 dys. "Rubeosis iridis." Severe vitreous hemorrhage. Moderate diabetic. Miotics failed.
R., 3/200, tension 90 mm. Hg; L. hand movements at 2 ft., tension 55 mm.
Lower 1/2 ofeach eye
3 dys. postoperatively, R. tension 40 mm., L. 55; 4 dyeR- 35, L. 40; 6 dys., R. 21, L. 25; 7 dya., R. 15, L. 17. Vision R. 7/200, L. 3/200. 30 dys., hypotony. 5 mos., severe bilateral proliferating retinitia. 6 mos., retinal separations with atrophic changes.
10.
80
9
Intracapsular combined cataract extraction* 3 yrs. previously. Moderate bullous keratitis. Miotics failed.
No light perception; tension 40-65 mm. Hg
Lower 1/2
4 days, postoperatively, tension 21 mm. 6 mos., 21.
68
o* Incompensated glaucoma 5 wks. after intracapsular combined cataract extraction. Miotics failed.
Light perception (previous to cataract operation) ; tension 40 mm. Hg
Lower 1 /2
Moderately severe postoperative reaction; 1 yr. postoperatively tension 10 mm. Corrected vision 6/30.
12.
55
9
R. no light per- Lower 2/5 ception; tension 90 mm. Hg
Phthisis bulbi. 3 mos. postoperatively enucleated.
13.
75
d* Chronic uveitis. Iris congested. No posterior synechia. Immature cataract. Cycloplegics failed.
Hand movements; tension 60 mm. Hg
Lower 1/3
2 dys. postoperatively, tension 40 mm.; 7 wks., 21; 6 mos., 16; 18 mos., extracapsular combined lens extraction. Vision: hand movements.
14.
73
9
Acute congestive glaucoma. Trephining* failed.
Light percer>tion, tension 90 + m m . Hg
Lower 1/2
4 mos. postoperatively, tactile tension normal. Light perception.
15.
59
9
Central venous thrombosis 1 yr. previously. A painful, congested eye with hyphemia.
No light perception.
Lower 3/5* Lens changes and posterior synechia. For 1-1/2 yrs. postoperatively, hypotony and free of pain.
16.
69
d* Bilateral acute congestive glaucoma. Left basal iridectomy* 2 yrs. previously. Miotics failed.
6/60; L. tension 90 + mm. Hg
Lower 1/2
17.
37
9
Finger counting; Upper 1/2* tension 55 mm. Hg
Bilateral chronic glaucoma untreated for 9 yrs. Right absolute glaucoma.
Glaucoma 9 dys. after central venous thrombosis. Moderate incompensation. Blood pressure 226/130.
3 dys. postoperatively, tension 35 mm. 3 wks., 25; 6 wks., 35. For 16 mos., 16-20 under miotics. Vision 6/60; Field, white 7/1000 12 30 12 18 10 dys. postoperatively, tension 20 mm. eyeball white in 2 mos.; 15 mos., tension 18.
DIATHERMY FOR THE TREATMENT OF GLAUCOMA
183
TABLE 1—Continued Case
Vision and Tension before Cyclodiathermy
Cyclodiathermy
Right chronic simple glaucoma. Trephine* 2 yrs. previously failed. Uncooperative in use of miotics. Left traumatic cataract of 24 yrs. duration. Posterior synechia, exotropia.
6/200; tension 40 mm. Hg
Upper 1/2
Hand movements; tension 40 mm. Hg
Upper 1/2
Extracapsular combined right cataract extraction* in 1936, and a later iridotomy* June, 1942. Pain and congestion. Fresh vitreous hemorrhage. Moderate diabetic.
Light perception; Upper 1/2 tension 30 mm. Hg
Bilateral chronic simple glaucoma. Right eye blind for 7 yrs. Moderate bullous keratitis. Slight congestion.
R. no light perception; tension 90 + mm. Hg No light perception ; tension 90 + mm. Hg
Upper 1/2
Intracapsular combined lens extraction* July, 1941. Sept., 1941, tension * 40 mm. March, 1942, tension 46. Cyclodialysis,* miotics failed. Eye irritated for 11 mos.
Finger counting; tension 55 mm. Hg
Upper 1/2
2 dys. postoperatively tension. 11 mm.; 2 wks.. 13; 2 mos., 29. Corrected vision 6/30. Comfortable.
Bilateral acute congestive glaucoma superimposed upon chronic simple glaucoma. Miotics failed.
Hand movements; L. tension 80 mm. Hg
Upper 1 /2 (Left)
1 wk. postoperatively, tension 19 mm.; 5 wks., 12; 2 mos., 48. Vision 6/200. Moderate cataractous changes and posterior synechia. Returned to miotics.
Light perception; Lower 1/2* tension 90 mm. Hg
2 dys. postoperatively, tension 48 mm. Eye injected for 6 mos. Tension 20 or lower for 21 yrs. Lens cataractous; posterior synechia. Comfortable without treatment.
Hand moveLower 2/5 ments; tension 90+mm. Hg Hand moveLower 1/2 ments; tension 90+mm. Hg
5 mos. postoperatively, hypotony. Phthisis bulbi.
Patient Diagnosis and Previous Treatment Age, Sex
9
Pain, congestion, iris vascular ization, posterior synechia, 8 mos. after central venous thrombosis.
22.
68
23.
62
24.
78
25.
65
Painful, congestive glaucoma 31 dys. following central venous thrombosis.
26.
55
27.
49
o" Internal strabismus, amblyopia exanopsia. Acute congestive glaucoma. Trephine, miotics failed. 9 Bilateral chronic simple glaucoma. Trephining* failed. Right acute congestive glaucoma. Miotics failed.
9
Anterior uveitis with old central chorioretinitis. Eye painful, congested. Vascular ization of iris sphincter. Corneal precipitates. No posterior synechia.
Fingers at 1 ft.; tension 70, after atropine 50 mm. Hg
Results 3 wks. postoperatively, tension 16 mm.; 4 wks., 29; 11 mos., 21; 23 mos., 21. Vision 1/200 3 wks. postoperatively, tension 23 mm.; 4 wks., 34; 11 mos., 25 when traumatic cataract was removed through enlarged upper keratome incision and broad basal iridectomy ;23 mos. after cyclodiathermy, tension 30. Corrected vision 6/15—2. Field white 3/1000 20 45 40 40 9 mos. postoperatively, tension 8 mm. No light perception.
5 dys. postoperatively, 41 mm.; 10 dys., 25; 2 mos., 16; 1 yr.. 10.
Upper 2/3* For 2 yrs. postoperatively, comfortable, without pain. Phthisis bulbi.
Lower 1/2
For 16 mos. postoperatively, tension 30-40 mm. under miotics. Vision 6/7.5. White field 3/1000 38 35 35 38 3 dys. postoperatively, tension 23 mm.; 6 dys., 16; 2 mos., 9; 5 mos., 16. Uveitis quiescentVision: fingers at 1 ft.
* Operation not performed by author. I am indebted to Dr. John F. Gipner for permission to include Cases 15 and 22, and to Dr. Charles T. Sullivan for Cases 17 and 25.
tone of the eyeball was reestablished. The majority of the cases in this series were in a state of vascular stasis and congestion preoperatively. Following operation, an incompensated phase was not again observed in any of these eyes. In cases 24 and 27 (chronic simple glaucoma which had become incompensated) there was relief from the acute state but they became stabilized at a glauco-
matous level. In these the reelevation of intraocular pressure occurred before the uveitis completely subsided. One is thereby confronted with the problem of whether or not to continue to treat the uveitis in an eye requiring a miotic for the glaucoma. The operation was most successful in the aphakic group. Tension was controlled in f\\e of the six cases of aphakia that
184
FRANK C. LUTMAN
were secondary to cataract extraction. The pain, incompensation, and at least part of the irritation were relieved in glaucoma secondary to central venous thrombosis. As the atrophy of the iris became more apparent, the uveitis in these eyes improved. A reduction in the number of new blood vessels upon the iris was not limited to the iris segment corresponding to the treated side of the eye. Glaucoma with rubeosis iridis in diabetics offers a no less hopeless prognosis. The neovascularization of the iris is a contraindication for intraocular surgery. In the single case (case 8) of rubeosis iridis treated by cyclodiathermy, the tension was controlled, but a later severe proliferating retinosis with an enormous number of new retinal blood vessels led to retinal separation and degenerative changes. Case 28 was a secondary glaucoma with anterior uveitis accompanying extensive vascularization over the sphincter muscle in a distribution similar to that observed in cases of acute rubeosis iridis. There were no posterior synechia. After cyclodiathermy, the congestion and pain disappeared, the tension remained within normal limits, and the uveitis subsided. In those cases where more advanced
degenerative changes were apparent and in absolute glaucoma, the operation tended to hasten the degeneration. The possibility of the glaucomatous eye containing a neoplasm must always be eliminated. CONCLUSIONS
In every instance where cyclodiathermy is contemplated one should not minimize the damage to the integrity of the eyeball, the unpredictable severity and frequently prolonged period of the postoperative uveitis, nor die uncertainty of a permanent control of the glaucoma. The operation is particularly suited to glaucoma where iris vascularization precludes surgery upon the iris, and to glaucoma secondary to central venous thrombosis. In the latter group, tension was not always controlled, but pain was relieved. Cyclodiathermy may be chosen as an operative procedure for some desperate cases, wherein already proved treatments for glaucoma have failed. It can be recommended in hopeless cases for the relief of glaucomatous pain in preference to enucleation, retrobulbar injection of alcohol, or to the X ray.
REFERENCES 1
Wagner, H., and Richner, H. Zyklodiathermiestichelung, eine neue Glaukomoperation. Schweiz. med. Woch., 1939, v. 69, Oct. 28, pp. 1048-1053. 1 Vogt, A. Ergebnisse der Diathermiestichelung des Corpus ciliare (Zyklodiathermiestichelung) gegen Glaukom. Klin. M. f. Augenh., 1937, v. 99, July, pp. 9-15. * . Die Zyklodiathermicpunkture (Z. D. P.) gegen Glaukom. Klin. M. f. Augenh., 1939, v. 103, Dec, pp. 591-599. 4 Albaugh, C. H., and Dunphy, E. B. Cyclodiathermy: An operation for the treatment of glaucoma. Arch, of Ophth., 1942, v. 27, March, pp. 543-547. 8 Duke-Elder, W. S. Text-book of ophthalmology. St. Louis, The C. V. Mosby Company, 1941, v. 3, p. 3396.
Vogt and his associates 1 ' 2 - 3 - have recently introduced the cyclodiathermy operation for the treatment of glaucoma. The operation employs a diathermy needle similar to that used for retinal separation to destroy a portion of the ciliary body by multiple punctures through the overlying sclera. An atrophy of the ciliary body has been confirmed histologically ;*■ * therefore a reduction in the formation of aqueous would be expected to follow. Vogt's procedure has been designated as "perforating cyclodiathermy" to distinguish it from the "nonperforating" method employed by Albaugh and Dunphy,4 who used contact with a broad electrode to the sclera over the ciliary region. The following report is based upon the observations made on 28 eyes afflicted with various types of glaucoma which were treated by nonperforating cyclodiathermy. The operative procedure followed closely the originally described method.4 Subsequent to instillation of an anesthetic and a retrobulbar injection of procaine and adrenalin, a conjunctival flap was reflected toward the limbus over half the eyeball. The tip of a 2-mm. rounded electrode was used in the earlier operations, and later the flat end of a round stainless-steel pin 2 mm. in diameter. A small Bovie high frequency electro-surgical unit set at 35-40 furnished the coagulation current. The electrode was held in contact with the sclera from 4 to 5 seconds to form a single row of points over the * From the Department of Surgery, The University of Rochester School of Medicine and Dentistry, and The Strong Memorial Hospital. t Now Lt. ( M C ) , A.U.S. 180
ciliary region. The amount of current, the time, and the degree of pressure upon the sclera are all variable and arbitrary. The optimum area of coagulation was for the 2 mm. covered by the tip of the electrode and extending for not more than 0.5 mm. beyond its edge. Coagulation exceeding this amount led to an excessive postoperative reaction. A closure with a tight running silk suture was found the most effective means of avoiding a postoperative retraction of the conjunctiva with an exposure of the treated portion of the sclera. In the few instances where retraction occurred, the sclera was slow in healing. Because of the possible danger of too extensive destruction to the anterior circulation of the eye, no more than twothirds of the ciliary body was treated in any one eye. At first, because intraocular pressure was not immediately relieved by the operation, there was hesitation in employing atropine postoperatively. Later atropine was used routinely and in most instances was continued until the uveitis subsided. At the first dressing of the atropinized eyes, the pupils were dilated only in the segment not operated upon. These pupils remained permanently oval, and the iris failed to respond to light over the segment that had undergone operation. Usually there was ocular pain for about 24 hours postoperatively, at which time the eyes were comfortable regardless of any abnormally high intraocular pressure. Albaugh and Dunphy4 attribute a postoperative rise in tension to a mechanical shrinking of the sclera with reduction of the total contents of the eyeball. Apart from this action there is the effect of the adrenalin used, for adrenalin temporarily
DIATHERMY FOR THE TREATMENT OF GLAUCOMA reduces intraocular pressure in a glaucomatous eye although it may later induce a stasis and edema.5 The elevated tension is probably due principally to the injurious effect of the diathermy upon the endothelium of those vessels of the ciliary body that are not actually destroyed. The injury is comparable to a burn upon the body surface where the transudate accumulates in cutaneous blebs. Occurring within the unyielding confines of the eyeball, this process is followed by extreme elevation of intraocular pressure. Occasionally, to counteract this, the operation was followed by a paracentesis sufficiently large to remain open for at least 24 hours. In most instances intraocular pressure dropped slowly and steadily for several days before it returned to normal. There was a further reduction to a point of extreme hypotony, lasting for weeks or until the uveitis subsided, when the tension returned to normal or again became elevated. During the stage of hypotony the anterior chamber was reduced as much as a third of normal depth. Several eyes were tender during this period. The preoperative incompensation and high tension were never reached by such eyes as returned to a glaucomatous state postoperatively. A most striking sequel of the operation was the relief from ocular pain. A constant occurrence was a faint opacification with anesthesia of one half to two thirds of the corneal surface corresponding to the treated segment of the bulbs. When three fifths of the ciliary region was treated, as much as four fifths of the cornea became anesthetic. For several subsequent weeks this hazy and anesthetic portion of the cornea dried quickly upon exposure. Later the corneal smoothness was completely restored, although in a few cases there were permanent deep nebulous opacities. These, however, may have arisen from the glaucoma. Corneal anesthesia over the segment
181
where it was first observed remained complete and unchanged in all these cases except one, where slight sensitivity returned. Some cases were under observation for more than two years. A number of cyclodiathermies were done upon the upper part of the bulb so that the anesthetic portion of the cornea was protected by the upper lid. This position of the cyclodiathermy did not interfere with a subsequent cataract extraction through an enlarged superiorly located keratome incision under a conjunctival flap in case 19. In case 13, the cyclodiathermy was below, the cataract incision located above. A uveitis with a cyclitis of variable severity and duration follows the necrosis of the ciliary body and overlying sclera. In this series there was a greatly increased aqueous ray which sometimes lasted for months. However, cells were infrequent in the anterior chamber. Some degree of posterior synechia usually occurred, and a mild iris atrophy was a frequent late finding. A thin membrane formed across the pupillary area of the aphakic eyes. Unless emptied by paracentesis, the anterior chamber usually remained at least partly formed, which is favorable in avoiding peripheral synechia. Danger of a direct thermal injury to the lens at operation seems improbable. Following any of the usual operations for glaucoma, even when no apparent injury occurs to the lens, cataractous changes are prone to form. With the use of cyclodiathermy a sudden acute fall of intraocular pressure is avoided. A possible danger to the lens exists in its exposure to an extreme hypotony, an iridocyclitis, and to the degenerative products from the tissues destroyed by the diathermy current. In spite of the destruction of a substantial part of the aqueous-forming structures, some eyes returned to an abnormally high tension when recovery from the operation had occurred and when the
182
FRANK C. LUTMAN TABLE 1 DATA ON 28 CASES OF GLAUCOMA TREATED WITH CYCLODLVTHERMY gex
Diagnosis and Previous Treatment
Vision and Tension before Cyclodiathermy
80
d"
Eye blind for 7 yrs. Iris atrophic, vascularized.
No light perception; tension 55 mm. Hg
2.
59
3.
Case A
Cyclodiathermy
Results
Lower 1/3
4 dys. postoperatively, tension 30 mm.; 3 wks., 21; 2 mos., 16.
d"1 Bilateral old retinal separations. Left eye painful, irritated. Mild diabetes.
Nolight percepUpper 2/5 tion; tension 90 mm. Hg
76
9
Acute congestive glaucoma 10 wks. following extracapsular combined lens extraction. Miotics failed.
6/200 (previous to cataract removal) ; tension 90 + mm. Hg
Upper 3/5
1 month postoperatively, tension 35 mm. No pain. Patient died soon after this from uremia. Tension followed for 16 mos. never above 21 mm. Corrected vision 6/7.5—2; Field, white 3/1000 3 5 8 27
4.
67
9
Irritation and pain 10 wks. after right central venous thrombosis. Miotics failed.
Light perception; tension 90 mm. Hg
Upper 3/5
1 wk. postoperatively, tension 42 mm.; 2 wks., 30; 5 wks., 25; 6 wks., 35.
5.
80
9
Right eye painful and congested for 10 dys. following central venous thrombosis of unknown duration.
Light perception; tension 90 mm. Hg
Upper 1/2
2 dys. postoperatively, tension 47 mm.; 4 dys., 55; 4 wks., 65; 5 wks., 80. No pain. Light perception.
6.
60
c? Left extracapsular lens extraction,* iridencleisis* 4 yrs. previously. Eye painful, congested.
No light perception; tension 9 0 + mm. Hg
Lower 1/2 (lightly)
2 dys. postoperatively, tension 35 mm.; 3 dys., 23; 3 mos., 55. No pain.
7.
66
9
Intracapsular combined cataract extraction* 1 yr. previously. Compensated glaucoma. Miotics failed.
6/10; tension 56 mm. Hg
Upper 2/3
1 dy. postoperatively, tension 21 mm.; 21 mos., 21. Corrected vision 6 / 1 0 - 2 ; Field 15 40 15 38
8,9.
52
In May, 1942, left acute congestive glaucoma for 33 dys.; right for 4 dys. "Rubeosis iridis." Severe vitreous hemorrhage. Moderate diabetic. Miotics failed.
R., 3/200, tension 90 mm. Hg; L. hand movements at 2 ft., tension 55 mm.
Lower 1/2 ofeach eye
3 dys. postoperatively, R. tension 40 mm., L. 55; 4 dyeR- 35, L. 40; 6 dys., R. 21, L. 25; 7 dya., R. 15, L. 17. Vision R. 7/200, L. 3/200. 30 dys., hypotony. 5 mos., severe bilateral proliferating retinitia. 6 mos., retinal separations with atrophic changes.
10.
80
9
Intracapsular combined cataract extraction* 3 yrs. previously. Moderate bullous keratitis. Miotics failed.
No light perception; tension 40-65 mm. Hg
Lower 1/2
4 days, postoperatively, tension 21 mm. 6 mos., 21.
68
o* Incompensated glaucoma 5 wks. after intracapsular combined cataract extraction. Miotics failed.
Light perception (previous to cataract operation) ; tension 40 mm. Hg
Lower 1 /2
Moderately severe postoperative reaction; 1 yr. postoperatively tension 10 mm. Corrected vision 6/30.
12.
55
9
R. no light per- Lower 2/5 ception; tension 90 mm. Hg
Phthisis bulbi. 3 mos. postoperatively enucleated.
13.
75
d* Chronic uveitis. Iris congested. No posterior synechia. Immature cataract. Cycloplegics failed.
Hand movements; tension 60 mm. Hg
Lower 1/3
2 dys. postoperatively, tension 40 mm.; 7 wks., 21; 6 mos., 16; 18 mos., extracapsular combined lens extraction. Vision: hand movements.
14.
73
9
Acute congestive glaucoma. Trephining* failed.
Light percer>tion, tension 90 + m m . Hg
Lower 1/2
4 mos. postoperatively, tactile tension normal. Light perception.
15.
59
9
Central venous thrombosis 1 yr. previously. A painful, congested eye with hyphemia.
No light perception.
Lower 3/5* Lens changes and posterior synechia. For 1-1/2 yrs. postoperatively, hypotony and free of pain.
16.
69
d* Bilateral acute congestive glaucoma. Left basal iridectomy* 2 yrs. previously. Miotics failed.
6/60; L. tension 90 + mm. Hg
Lower 1/2
17.
37
9
Finger counting; Upper 1/2* tension 55 mm. Hg
Bilateral chronic glaucoma untreated for 9 yrs. Right absolute glaucoma.
Glaucoma 9 dys. after central venous thrombosis. Moderate incompensation. Blood pressure 226/130.
3 dys. postoperatively, tension 35 mm. 3 wks., 25; 6 wks., 35. For 16 mos., 16-20 under miotics. Vision 6/60; Field, white 7/1000 12 30 12 18 10 dys. postoperatively, tension 20 mm. eyeball white in 2 mos.; 15 mos., tension 18.
DIATHERMY FOR THE TREATMENT OF GLAUCOMA
183
TABLE 1—Continued Case
Vision and Tension before Cyclodiathermy
Cyclodiathermy
Right chronic simple glaucoma. Trephine* 2 yrs. previously failed. Uncooperative in use of miotics. Left traumatic cataract of 24 yrs. duration. Posterior synechia, exotropia.
6/200; tension 40 mm. Hg
Upper 1/2
Hand movements; tension 40 mm. Hg
Upper 1/2
Extracapsular combined right cataract extraction* in 1936, and a later iridotomy* June, 1942. Pain and congestion. Fresh vitreous hemorrhage. Moderate diabetic.
Light perception; Upper 1/2 tension 30 mm. Hg
Bilateral chronic simple glaucoma. Right eye blind for 7 yrs. Moderate bullous keratitis. Slight congestion.
R. no light perception; tension 90 + mm. Hg No light perception ; tension 90 + mm. Hg
Upper 1/2
Intracapsular combined lens extraction* July, 1941. Sept., 1941, tension * 40 mm. March, 1942, tension 46. Cyclodialysis,* miotics failed. Eye irritated for 11 mos.
Finger counting; tension 55 mm. Hg
Upper 1/2
2 dys. postoperatively tension. 11 mm.; 2 wks.. 13; 2 mos., 29. Corrected vision 6/30. Comfortable.
Bilateral acute congestive glaucoma superimposed upon chronic simple glaucoma. Miotics failed.
Hand movements; L. tension 80 mm. Hg
Upper 1 /2 (Left)
1 wk. postoperatively, tension 19 mm.; 5 wks., 12; 2 mos., 48. Vision 6/200. Moderate cataractous changes and posterior synechia. Returned to miotics.
Light perception; Lower 1/2* tension 90 mm. Hg
2 dys. postoperatively, tension 48 mm. Eye injected for 6 mos. Tension 20 or lower for 21 yrs. Lens cataractous; posterior synechia. Comfortable without treatment.
Hand moveLower 2/5 ments; tension 90+mm. Hg Hand moveLower 1/2 ments; tension 90+mm. Hg
5 mos. postoperatively, hypotony. Phthisis bulbi.
Patient Diagnosis and Previous Treatment Age, Sex
9
Pain, congestion, iris vascular ization, posterior synechia, 8 mos. after central venous thrombosis.
22.
68
23.
62
24.
78
25.
65
Painful, congestive glaucoma 31 dys. following central venous thrombosis.
26.
55
27.
49
o" Internal strabismus, amblyopia exanopsia. Acute congestive glaucoma. Trephine, miotics failed. 9 Bilateral chronic simple glaucoma. Trephining* failed. Right acute congestive glaucoma. Miotics failed.
9
Anterior uveitis with old central chorioretinitis. Eye painful, congested. Vascular ization of iris sphincter. Corneal precipitates. No posterior synechia.
Fingers at 1 ft.; tension 70, after atropine 50 mm. Hg
Results 3 wks. postoperatively, tension 16 mm.; 4 wks., 29; 11 mos., 21; 23 mos., 21. Vision 1/200 3 wks. postoperatively, tension 23 mm.; 4 wks., 34; 11 mos., 25 when traumatic cataract was removed through enlarged upper keratome incision and broad basal iridectomy ;23 mos. after cyclodiathermy, tension 30. Corrected vision 6/15—2. Field white 3/1000 20 45 40 40 9 mos. postoperatively, tension 8 mm. No light perception.
5 dys. postoperatively, 41 mm.; 10 dys., 25; 2 mos., 16; 1 yr.. 10.
Upper 2/3* For 2 yrs. postoperatively, comfortable, without pain. Phthisis bulbi.
Lower 1/2
For 16 mos. postoperatively, tension 30-40 mm. under miotics. Vision 6/7.5. White field 3/1000 38 35 35 38 3 dys. postoperatively, tension 23 mm.; 6 dys., 16; 2 mos., 9; 5 mos., 16. Uveitis quiescentVision: fingers at 1 ft.
* Operation not performed by author. I am indebted to Dr. John F. Gipner for permission to include Cases 15 and 22, and to Dr. Charles T. Sullivan for Cases 17 and 25.
tone of the eyeball was reestablished. The majority of the cases in this series were in a state of vascular stasis and congestion preoperatively. Following operation, an incompensated phase was not again observed in any of these eyes. In cases 24 and 27 (chronic simple glaucoma which had become incompensated) there was relief from the acute state but they became stabilized at a glauco-
matous level. In these the reelevation of intraocular pressure occurred before the uveitis completely subsided. One is thereby confronted with the problem of whether or not to continue to treat the uveitis in an eye requiring a miotic for the glaucoma. The operation was most successful in the aphakic group. Tension was controlled in f\\e of the six cases of aphakia that
184
FRANK C. LUTMAN
were secondary to cataract extraction. The pain, incompensation, and at least part of the irritation were relieved in glaucoma secondary to central venous thrombosis. As the atrophy of the iris became more apparent, the uveitis in these eyes improved. A reduction in the number of new blood vessels upon the iris was not limited to the iris segment corresponding to the treated side of the eye. Glaucoma with rubeosis iridis in diabetics offers a no less hopeless prognosis. The neovascularization of the iris is a contraindication for intraocular surgery. In the single case (case 8) of rubeosis iridis treated by cyclodiathermy, the tension was controlled, but a later severe proliferating retinosis with an enormous number of new retinal blood vessels led to retinal separation and degenerative changes. Case 28 was a secondary glaucoma with anterior uveitis accompanying extensive vascularization over the sphincter muscle in a distribution similar to that observed in cases of acute rubeosis iridis. There were no posterior synechia. After cyclodiathermy, the congestion and pain disappeared, the tension remained within normal limits, and the uveitis subsided. In those cases where more advanced
degenerative changes were apparent and in absolute glaucoma, the operation tended to hasten the degeneration. The possibility of the glaucomatous eye containing a neoplasm must always be eliminated. CONCLUSIONS
In every instance where cyclodiathermy is contemplated one should not minimize the damage to the integrity of the eyeball, the unpredictable severity and frequently prolonged period of the postoperative uveitis, nor die uncertainty of a permanent control of the glaucoma. The operation is particularly suited to glaucoma where iris vascularization precludes surgery upon the iris, and to glaucoma secondary to central venous thrombosis. In the latter group, tension was not always controlled, but pain was relieved. Cyclodiathermy may be chosen as an operative procedure for some desperate cases, wherein already proved treatments for glaucoma have failed. It can be recommended in hopeless cases for the relief of glaucomatous pain in preference to enucleation, retrobulbar injection of alcohol, or to the X ray.
REFERENCES 1
Wagner, H., and Richner, H. Zyklodiathermiestichelung, eine neue Glaukomoperation. Schweiz. med. Woch., 1939, v. 69, Oct. 28, pp. 1048-1053. 1 Vogt, A. Ergebnisse der Diathermiestichelung des Corpus ciliare (Zyklodiathermiestichelung) gegen Glaukom. Klin. M. f. Augenh., 1937, v. 99, July, pp. 9-15. * . Die Zyklodiathermicpunkture (Z. D. P.) gegen Glaukom. Klin. M. f. Augenh., 1939, v. 103, Dec, pp. 591-599. 4 Albaugh, C. H., and Dunphy, E. B. Cyclodiathermy: An operation for the treatment of glaucoma. Arch, of Ophth., 1942, v. 27, March, pp. 543-547. 8 Duke-Elder, W. S. Text-book of ophthalmology. St. Louis, The C. V. Mosby Company, 1941, v. 3, p. 3396.